Loading
Form preview picture

Get Form Approval Omb 0910 0502

Form Approval OMB No. 0910-0502 Expiration Date 10/31/2006 See OMB Statement at end of form FDA USE ONLY USE BLUE OR BLACK INK ONLY DHHS/FDA CANCELLATION OF FOOD FACILITY REGISTRATION FORM PIN FACILITY REGISTRATION NUMBER O DOMESTIC REGISTRATION FOREIGN REGISTRATION FACILITY NAME / ADDRESS INFORMATION FACILITY STREET ADDRESS Line 1 CITY STATE ZIP CODE POSTAL CODE PROVINCE/TERRITORY COUNTRY CERTIFICATION STATEMENT The owner operator or agent in charge of the facility or an individual authorized by the owner operator or agent in charge of the facility must submit this form. By submitting this form to FDA or by authorizing an individual to submit this form to FDA the owner operator or agent in charge of the facility certifies that the above information is true and accurate. An individual other than the owner operator or agent in charge of the facility who submits the form to the FDA also certifies that the above information submitted is true and accurate and that he/she is authorized to submit the cancellation on the facility s behalf* An individual authorized by the owner operator or agent in charge must below identify by name the individual who authorized submission of the cancellation* Under 18 U*S*C. 1001 anyone who makes a materially false fictitious or fraudulent statement to the U*S* Government is subject to criminal penalties. SIGNATURE OF SUBMITTER PRINT NAME OF THE SUBMITTER CHECK ONE BOX O A. OWNER OPERATOR OR AGENT IN CHARGE STOP HERE FORM IS COMPLETED O B. INDIVIDUAL AUTHORIZED TO SUBMIT THE CANCELLATION FILL IN BELOW IF YOU CHECKED BOX B ABOVE INDICATE WHO AUTHORIZED YOU TO SUBMIT THE CANCELLATION O NAME OF INDIVIDUAL WHO AUTHORIZED CANCELLATION ON BEHALF OF OWNER OPERATOR OR AGENT IN CHARGE FILL IN BELOW ADDRESS INFORMATION FOR THE AUTHORIZING INDIVIDUAL AUTHORIZING INDIVIDUAL ADDRESS Line 1 PHONE NUMBER Include Area/Country Code DATE CANCELLATION FORM RECEIVED DATE CONFIRMATION SENT TO FACILITY MAIL COMPLETED FORM TO U*S* FOOD AND DRUG ADMINISTRATION HFS-681 5600 FISHERS LANE ROCKVILLE MD 20857 OR FAX IT TO 301 210-0247. Public reporting burden for this collection of information is estimated to average 1 hour per response including the time for reviewing instructions searching existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information* Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to Department of Health and Human Services An agency may not conduct or sponsor and a Food and Drug Administration person is not required to respond to a collection of CFSAN/PRB Comments HFS-024 information unless it displays a currently valid 5100 Paint Branch Parkway OMB control number. An individual other than the owner operator or agent in charge of the facility who submits the form to the FDA also certifies that the above information submitted is true and accurate and that he/she is authorized to submit the cancellation on the facility s behalf* An individual authorized by the owner operator or agent in charge must below identify by name the individual who authorized submission of the cancellation* Under 18 U*S*C. 1001 anyone who makes a materially false fictitious or fraudulent statement to the U*S* Government is subject to criminal penalties.

How It Works

dhhs rating
4.8Satisfied
52 votes

Tips on how to fill out, edit and sign Submits online

How to fill out and sign Certification online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Legal, tax, business and other e-documents need a top level of compliance with the legislation and protection. Our forms are regularly updated according to the latest legislative changes. In addition, with us, all the info you provide in the Form Approval Omb 0910 0502 is well-protected from loss or damage with the help of top-notch file encryption.

The following tips will allow you to fill in Form Approval Omb 0910 0502 easily and quickly:

  1. Open the template in our feature-rich online editor by clicking Get form.
  2. Fill out the required fields that are colored in yellow.
  3. Click the green arrow with the inscription Next to jump from one field to another.
  4. Use the e-autograph tool to put an electronic signature on the template.
  5. Add the date.
  6. Double-check the whole template to make sure you haven?t skipped anything.
  7. Press Done and download the resulting template.

Our service allows you to take the whole procedure of completing legal forms online. For that reason, you save hours (if not days or weeks) and eliminate unnecessary payments. From now on, complete Form Approval Omb 0910 0502 from home, business office, as well as on the move.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Certifies FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Form Approval Omb 0910 0502

  • HFS-681
  • false
  • dhhs
  • Rockville
  • 3537a
  • cfsan
  • certifies
  • materially
  • submits
  • fishers
  • fraudulent
  • Certification
  • submitting
  • authorizing
  • fictitious
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.